Online cost-benefit tool for contraceptive programmes

Demo version of a cost-benefit tool for contraceptive programmes

Hello, my name is Jari Kempers. I’m a health economist. With this short video, I’m going to present you a demo version of a cost-benefit tool that we have built for contraceptive programmes.

What is it?

It is an online tool that models health outcomes, and it compares the investment needed with the potential cost savings. And so, therefore, it is a cost-benefit analysis. 

But more importantly, it is an advocacy and presentation tool. And it is used together with an investment case. So say, a three four-page document that you hand out to your counterparts in the meetings with the concrete recommendations and short to the point information. In essence, it is advocacy, supported by health economics.

In essence, it is advocacy, supported by health economics.
You want to convince the decision-makers that the contraceptives are a good cost-saving investment. 

Background

First of all, experienced health economists are in short supply. And then finally you find one, and you get your study done. My observation is that health economic reports and studies are often, say underutilized, or only used once when the health economist is there and presents the work. And then it is not used anymore. So it’s not a very effective way of using these types of studies. And also, my observation is that the medical personnel are often not comfortable reusing or presenting these studies. 

That’s why we started thinking about how we could help? How health economics work could be used more effectively and longer? That’s why we both built this online tool. And we paid special attention, and we limited the number of inputs that the user needs to use. And also, we made a kind of build-up on how the results are presented. So in a minute, I’ll show you the tool itself. 

For whom it is?

The target audience, they are healthcare policymakers, the Ministry of Health, in some countries health insurance or the Ministry of Finance people. And is used by international organizations or SRH experts, and in general, persons who are not health economists. 

Health economics service

What we offer is a health economics service. We do data collection that is needed to be done in order for the model to work in your situation. We collect the data on the contraceptives, contraceptive prevalence rate (mCRP), the method mix, the policy goals and so forth. There are also health outcome data what needs to be collected and costing of the family planning services. 

The cost of providing the contraceptives and also inputs needed for modelling the averted healthcare costs. We localize the model to work in your country, but what is more important is that it needs to work hand in hand with the current advocacy messages, what we are currently working on, so they are working together. 

We write an investment case, a three-page policy brief, investment case for the healthcare decision-makers with the concrete recommendations and straightforward results that they can easily get quickly from the document. And then we will leave you with the online tool, we do the base case. But later, you can do your own scenarios and you can save them on the tool, say, your method mix changes or your policy goal goes up or down. And you can model then yourself the economic impacts of the changes. I’ll show you a quick introduction to the online tool. I’ll show the user set up, the inputs what you need to choose, and then I’ll show you the results and the summary. In this video, we will skip the advanced inputs to save time. Okay, let’s get started.

Setup

So here, I’m going to walk you through the model as you would be using it in your meetings. We have on purpose limited the number of the inputs that the user needs to select. You start by selecting the time horizon. Typically, the year when you have the latest contraceptive prevalence rate data, in this exercise we assume that is 2020. Then, if your country has a five-year policy call, then you choose a target for five years. If you have, say, three years left of the plan, then you can choose a shorter time horizon. Here we have five years, from 2020 to 2025.

Geographic area

We can put multiple countries in the tool. In this case, I’ll show Mozambique. We have here multiple countries already in.  You can choose then the geographic area. Typically countries deal with the entire country, but in some countries where there is a fragmented governmental structure and the procurement of contraceptives is pushed towards the local authorities, you may want to choose a province or even a city. Just that your numbers reflect the reality of what these decision-makers are dealing with. In this case, we will look at the entire country. 

Population

Next, you can choose different populations, say all women or in-union. You can also add adolescents, different age groups, or vulnerable groups. Here one should not do overkill. One should only choose the ones that you’re currently advocating for. In this case, we will look at women in-union, 15 to 49 years old. 

Contraceptive prevalence rate

The whole forecast is driven by a modern contraceptive prevalence rate (mCRP). In the setup, we will put the current method mix. Different long-acting and short-acting methods, and the current portions. 

Then you have the policy goal. In this case, we are advocating for a 5% increase in the uptake. Then you put the targeted contraceptive method mix for this year. It is all done here in the setup. Then the tool shows you the current method mix, and also the population.  Say, here we have all the women and this is in-union. What we are actually looking at. Then, once you have selected all these. I jump right away to the results. 

Results

This is what you would use in your meetings. So, the point here is that we want to build up the results in a way that the policymakers, who are not experts in contraceptives or family planning, can still understand this. 

Here, we are advocating for a 5% increase mCRP from 35% to 40% in five years time. What would it mean in terms of family planning users? So, in-union, this would mean from 1.6 million to 2.1 million in five years time. 

Health outcomes

What does it mean then in terms of health outcomes, if you have more family planning users? There are obviously less unintended pregnancies, and because there are fewer pregnancies, you have fewer live-births and abortions.  Here we get the numbers for each year, and we have numeric tables for all of them. Then, because we have fewer pregnancies, you have fewer deliveries, abortions, you have a reduction in maternal mortality. In this case, there would be 3,300 deaths averted in the beginning, and that would increase to 4,400 averted deaths per year at the end of the forecast. 

Investment needed

Then, there are two sides of the story. You have the investment needed, and you have the cost savings caused by the contraceptive use. First, we saw that the cost of family planning services. First of all, this shows that in five years, one would need a $50 million investment. This shows where the money would be spent. 

Mainly on injectables and pills, and some on condoms. This is not just the devices or pills. Here the costing, what is done as a preparation for the model. It includes then consultations, say, you have an intake consultation, you have insertion or operation, then you have a control visit, yearly control visits or removals, all these things. It also depends on who is doing these consultations. Is it a midwife, GP or specialist? They all carry different time costs. This is based on the costing study. 

Averted healthcare costs

Then the other side of the story is the averted healthcare costs. Because there are less pregnancies, less antenatal care and delivery care needed. There are less complications, there are less unsafe abortion-related care needed. 

We saw in the previous tab that $50 million investment was needed. And the potential savings during this period would accumulate up to $172 million. Then we bring these together. This is the investment what you are lobbying for. The potential healthcare cost savings would be $172 million.

Cost-benefit analysis

Then these would be the net savings for the Ministry of Health. This demonstrates that contraceptives would be a very good investment for the money of the Ministry of Health. Then we bring these also together for cost-benefit analysis. We add the yearly investment needed and the potential cost savings for every year. 

Summary

Obviously, this is quite a lot of information for a decision-maker. Then we want you to be able to wrap up the meeting. In the way that they remember things, and here we have this kind of cards.  For the five years, you would need to invest $50 million. At the end of the forecast, 2025, you have 2.1 million users. During the whole five year period, you would avert 3.6 million unintended pregnancies. Maternal deaths would be reduced by 23,000. And potential healthcare costs savings would be $172 million. And this would mean that the return on investment would be 1 to 3. Meaning that $1 spent on the contraceptives would save you potentially $3. 

Interesting for your programme?

I hope you liked the modelling tool. If this is something for your country or for your programme, please send me an email and we can schedule another call to discuss the details.

Economic Analysis of Youth Sexual and Reproductive Health Programs

Phd thesis of by Dr Jari Kempers, health economist PhD, Economic Analysis of Youth Sexual and Reproductive Health Programmes

Sexual and reproductive health (SRH) programmes for young people have a high priority in many low- and middle-income countries (LMICs). However, little is known about the economic aspects of these programmes. More information is needed to support policymaking and to accelerate the implementation of these programmes. This multi-country PhD thesis provides new evidence on costs and cost-effectiveness of young people’s SRH programmes in resource-limited settings. The six research papers are intended for national healthcare policymakers and public health programme managers in LMICs, and personnel of international organizations supporting their work. The World Health Organization (WHO) recommends the simultaneous implementation of health promotion and healthcare services. This thesis focuses on economic evaluations of these two pillars in the context of young people’s SRH. It is organized in two thematic sections; first school-based sexuality education (SBSE) programmes, and second youth-friendly sexual and reproductive health (YFSRH) services.

PhD book of Dr Jari Kempers

This is a PhD thesis of Jari Kempers: Economic Analysis of Youth Sexual and Reproductive Health Programmes – a Multi-Country Study.

Contact the author
Jari Kempers, health economist PhD
jari.kempers (a) Qalys.eu

Please cite this book as
Kempers Jari. Economic Analysis of Youth Sexual and Reproductive Health Programmes – a Multi-Country Study. 2015. ISBN: 978-94-6259-771-6. http://www.Qalys.eu/PhD-Jari-Kempers

Would you like to have a beautiful hard copy of the book? Please send an email to Jari Kempers. The price of the book is 10€ + postage.
© Jari Kempers 2015

All rights are reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, without permission of the author.

School-based sexuality education programs

The first thematic section presents economic analyses of school-based sexuality education programmes. There are numerous SBSE implementation guidelines for policy makers and programme managers. However, they are often left in the dark on budget implications and efficient design of SBSE programmes. The thesis addresses this by providing cost analyses and -comparisons of six real-world SBSE programmes in India, Indonesia, Kenya, Nigeria, Estonia and the Netherlands, by identifying efficient SBSE programme types and conducting an exploratory cost-effectiveness analysis on one the programmes.

This thesis suggests that SBSE programmes are potentially cost-saving and cost-effective in their public health objective to reduce unintended pregnancies, STIs and HIV infections. However, these outcomes are dependent on programme characteristics and context. The thesis demonstrates that SBSE programmes can be produced at a low cost per student when implemented as large scale intra-curricular programmes. It recommends countries to invest in scalable comprehensive intra-curricular SBSE programme models, that have demonstrated their effectiveness in a similar context. Moreover, the thesis shows that a context where sexuality is a sensitive issue increases costs and reduces the potential impact of SBSE programmes. The opposition has consequences for how and the pace at which SBSE programmes can be introduced and scaled-up, and for the content of sexuality education, i.e. comprehensive versus abstinence-only. Advocacy plays a key role in the success of the implementation of SBSE programmes. Advocacy appears to be a significant cost component, throughout all implementation phases, in many SBSE programmes. Despite this, advocacy is often not budgeted. Therefore, the thesis advises policymakers and programme managers to consider advocacy as a necessary and continuous investment. Lastly, a combination of SBSE and YFSRH services appears to be particularly effective.

Youth-friendly sexual and reproductive health services

The second thematic section presents economic analyses of youth-friendly sexual and reproductive health services. Young people have different healthcare needs and preferences than adults or children. It is important that healthcare systems offer youth-friendly SRH services that are accessible, acceptable and appropriate for young people. However, there is no single YFSRH service package that suits every country. Each country has to define its own package according to epidemiological, social and economic circumstances. This thesis supports these efforts by providing new evidence on the costs of two YFSRH services programmes in Estonia and Moldova, and on the cost-effectiveness of the latter programme. These programmes were selected because former Soviet Union and Eastern European countries are one of the frontiers in developments in young people’s SRH.

The thesis demonstrates that YFSRH services can be produced at a relatively low cost per patient. However, there is no clear answer to whether or not the YFSRH services are cost-saving and cost-effective. This is highly dependable on epidemiological context, especially HIV, and quality of the services. Nevertheless, the thesis recommends countries to invest in YFSRH services, which are an essential part of efforts to improve young people’s SRH, and to implement them together with SBSE programmes. Four chapters of this thesis include young people’s SRH programmes in Estonia. The country has become an internationally recognized success story on scaling up and sustaining national young people’s SRH programmes, with simultaneously improved SRH outcomes. A policy analysis summarizes the factors that contributed to successful scale-up of Estonian youth clinic network (YCN). First, Estonia had a favourable social and political climate for offering YFSRH services. Second, there was a clearly demonstrated need for the services. Third, there is a national professional organization, Estonian Sexual Health Association (ESHA), coordinating and representing youth clinics (YCs). Fourth, personnel of ESHA and YC’s played an important active role in advocating YFSRH services to policymakers. Fifth, the YCs receive sustainable funding through the national health insurance system. Sixth, the recognition of the improvements would not have been possible without the development of national reporting and monitoring systems, and many studies and international publications.

Measurement and attribution of impacts of young people’s SRH programs

This thesis demonstrates challenges with and provides recommendations for, measurement and attribution of impacts of the young people’s SRH programmes. It identifies the following main challenges with assessing the impacts of SBSE programmes: First, the long duration of SBSE programmes makes the use of pre- and post-measurements difficult and lengthy. Second, comparable control groups do not exist. Especially with integrated SBSE programmes, which are usually implemented country- or state-wide. Third, reliable SRH outcome data is not available, or even if data is available the challenge with attribution remains. Fourth, there is a delay between sexuality education (SE) and start of sexual intercourse. At the beginning of the SE programme pupils are usually quite young and not sexually active. They become sexually active several years later, and only then the impact can be assessed. Impact of YFSRH services is a combined result of healthcare services and health promotion. The challenges with assessing of impacts of YCs’ health promotion activities are similar to SBSE programmes. Comparable control groups and reliable SRH impact data do not exist, and there may also be a delay between health promotion and sexual behaviour. Measuring and attributing impacts of YCs’ healthcare services is easier. YCs usually have records on provided SRH services, which can be used for quantifying primary impacts of the healthcare services.

Despite these challenges, the thesis argues that assessing the impact and cost-effectiveness of young people’s SRH programmes is possible. It makes the following recommendations: First, impact- and economic evaluations of young people’s SRH programmes should be combined and planned together in advance. Second, a case-control design is a recommended approach. This requires identification of a comparable control group, or dividing sites randomly into intervention and control groups. Third, base-line measurements should be collected in both groups before the intervention begins. Fourth, special attention should be paid to that data collection captures the information needed for cost-effectiveness analysis. Priority should be given to health outcomes, and if these are not available then behaviour change outcomes should be collected. Fifth, a follow-up period should be for several years. It is important that individuals can be tracked and followed up over time.

Comparability of economic evaluations of young people’s SRH programs

The literature review for this thesis shows that economic evaluations of young people’s SRH programmes are scarce. The results of identified studies are largely incomparable, because the programmes and their contexts, research objectives and used evaluation methods are different, and due to a lack of transparency in documentation as well. The literature review process revealed that there are numerous publications on the impact and effectiveness of young people’s SRH programmes. Yet, very few had any cost- or cost-effectiveness components. This is surprising, especially because financial constraints are one of the main bottlenecks of implementation of young people’s SRH programmes. Most of the impact-only studies measure behaviour intentions (knowledge, skills, attitude) or behaviour changes (abstinence, condom use, number of sex partners), which are much easier to obtain and less suitable for cost-effectiveness analyses than health outcomes (pregnancies, abortions, STIs and HIV infections). Most of the identified economic analyses are limited to only HIV infections (cost per averted HIV infection and/or cost per DALY). The choice is understandable because averted HIV infections create the highest cost savings.

The thesis makes the following suggestions for building an evidence base and improving comparability of economic evaluations of young people’s SRH programmes. First, efforts should be made to combine impact studies with economic evaluations. Second, more attention should be paid to the use of comparable methods and indicators in economic evaluations of SRH programmes. Third, the results of economic evaluations should be compared. Fourth, documentation of methods, data and sources of economic evaluations of SRH programmes should be improved. Transparent reporting will improve the comparability of economic evaluations in the future.

Finally, the thesis makes the following general recommendations for economic evaluations of young people’s SRH programmes. Economic analyses should always aim to support decision making. These should be designed to answer questions that decision-makers are dealing with, and analyses should focus only on issues that are relevant for policymaking. Especially with young people’s SRH programmes health economists need to balance urgency for action (programme implementation) with the long time required for the collection of better data (impact and cost). In the low- and middle-income country context, affordability is the primary and often the only economic criterion included in the decision making process. Therefore the sequence of questions that economic evaluations address should be: How much the programme cost? Does it create cost savings somewhere else? Is it cost-effective? Lastly, complex research results should be simplified and communicated to decision-makers in their language.